4

Assessment of Level of Need for Geriatricians and Faculty

FACULTY FOR TEACHING NEEDS

In the 1980 study by the University of California, Los Angeles (UCLA), and the RAND Corporation, it was estimated there was a need for between 900 and 1,600 faculty in geriatric medicine, 1,300 Ph.D. basic scientists in geriatric medicine, and 450 geropsychiatrists to serve the needs of academic geriatric medicine alone. That study also estimated the total need of physician faculty of 2,100 and 8,000 full-time equivalent (FTE) geriatric specialists (including 1,100 geropsychiatrists) by the year 2000. These estimates were based on the assumption that geriatricians would provide improved care to people over age 75 as consultants and primary care givers, with the delegation of a moderate amount of responsibility to nurse practitioners, physician's assistants, and social workers (Kane et al., 1980a).

Other groups, such as the Association of Program Directors of Internal Medicine and the American Academy of Family Physicians (AAFP) have also made estimates. The former estimated that 1600 academic geriatricians are needed for the approximately 800 internal medicine and family practice residency programs; the AAFP estimated that 400 qualified faculty are needed for the existing family practice residency programs.

In its document Personnel for Health Needs of the Elderly through Year 2020, the National Institute on Aging (NIA) (1987) estimated the need for 1,000 to 2,000 academic geriatricians both in the year 2000 and in 2020. More recent estimates have predicted the need for geriatrics physician faculty ( Table 3) to



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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions 4 Assessment of Level of Need for Geriatricians and Faculty FACULTY FOR TEACHING NEEDS In the 1980 study by the University of California, Los Angeles (UCLA), and the RAND Corporation, it was estimated there was a need for between 900 and 1,600 faculty in geriatric medicine, 1,300 Ph.D. basic scientists in geriatric medicine, and 450 geropsychiatrists to serve the needs of academic geriatric medicine alone. That study also estimated the total need of physician faculty of 2,100 and 8,000 full-time equivalent (FTE) geriatric specialists (including 1,100 geropsychiatrists) by the year 2000. These estimates were based on the assumption that geriatricians would provide improved care to people over age 75 as consultants and primary care givers, with the delegation of a moderate amount of responsibility to nurse practitioners, physician's assistants, and social workers (Kane et al., 1980a). Other groups, such as the Association of Program Directors of Internal Medicine and the American Academy of Family Physicians (AAFP) have also made estimates. The former estimated that 1600 academic geriatricians are needed for the approximately 800 internal medicine and family practice residency programs; the AAFP estimated that 400 qualified faculty are needed for the existing family practice residency programs. In its document Personnel for Health Needs of the Elderly through Year 2020, the National Institute on Aging (NIA) (1987) estimated the need for 1,000 to 2,000 academic geriatricians both in the year 2000 and in 2020. More recent estimates have predicted the need for geriatrics physician faculty ( Table 3) to

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions range from a low of 277 in rehabilitation to a high of 2,407 in internal medicine (Reuben et al., 1993a). These estimates are based on (1) the minimum number, or “critical mass,” of faculty needed to sustain a division (or comparable unit) of geriatrics or (2) the number of faculty estimated to provide “core” geriatrics training as defined by the American Geriatrics Society Education Committee. When compared with the current supply of geriatrics physician faculty (see above), these figures suggest that the current supply of geriatrics physician faculty is less than half the number needed in each specialty. Moreover, given the current capacity for training, there will be a net loss of such faculty each year in each specialty. These projected faculty needs do not include the additional faculty that might be required for continuing medical education. FACULTY FOR RESEARCH NEEDS A number of attempts at projecting the needs of faculty for research in geriatrics and gerontology have been made. The first was the 1980 UCLA-RAND study in which it was estimated that there was a need for between 900 and 1,600 geriatric medicine faculty, 1,300 Ph.D. basic scientists, and 450 geropsychiatrists to serve the needs of academic geriatric medicine alone. That study did not delineate the percentage of time that they envisaged physicians in academic medicine would spend on research, although the researchers assumed that at least half of their time would be devoted to this endeavor. They assumed that the 1,300 Ph.D. basic scientists would be fully engaged in research activities. In 1987, NIA, in a report to the U.S. Congress, made the observation that the number of trainees in clinical and biomedical research on aging was far short of the number needed at that time and recommended that the first step that needed to be taken to repair this deficiency included the provision of support for 200 additional trainees per year in basic biomedical science. In the same report, NIA predicted that there was a need for 1,500 nonbiomedical faculty, including behavioral and social scientists, by 1990 to fulfill the research needs in the field of aging and that more than 3,500 such professionals would be needed by the year 2000. The report observed that only a small percentage of the training needs for 1990 had been met at that time and, thus, recommended an additional 200 doctoral trainees per year in the behavioral and social sciences in aging and an additional 140 trainees per year in health services research (U.S. Department of Health and Human Services, 1987). The 1987 Institute of Medicine (IOM) study recommended that the number of graduates in academic geriatric programs in schools of medicine be increased from the 1987 level of 100 per year to 200–250 per year to meet the estimated 2,100 medical faculty members needed in the field by the year 2000 (Institute of Medicine, 1987). Another IOM study, entitled A National Research Agenda on

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions Aging: Extending Life, Enhancing Life, (Institute of Medicine, 1991) recommended that additional funds should be phased in over a 5-year period to implement this recommendation and assumed that advanced training programs would last 2 to 3 years and would thus support an additional 200–300 trainees at all levels. In addition, the report recommended that funds be provided for 100 –150 junior faculty investigators engaged in research on aging. The same IOM report observed that the existing training programs in aging-related research in schools of medicine were undersubscribed and suggested that it might be more prudent to phase in more support for training programs after it had been demonstrated that the increased investment in research that was taking place was attracting more students to the field. The report stated that the current cadre of faculty members with age-related research interests was adequate to provide initial training for increased numbers of students in the area. Subsequent workforce and personnel projections would suggest that this observation is incorrect. The present academic leadership in geriatric medicine believes that the training capacity at the various Centers of Excellence exceeds the level of funding needed to support advanced trainees and that if adequate funding was provided to meet the present training capacity, competent advanced trainees would oversubscribe the training programs (Kowal, 1993). The IOM committee suggested that an additional 200 doctoral trainees in the behavioral and social sciences and an additional 140 trainees in health services research would be needed each year. The committee used the assumption that the average cost would be $50,000 per trainee and that since approximately 1,000 additional trainees were recommended, the non-inflation-adjusted cost for this training effort would be $50 million per year phased in over a 5-year period (Institute of Medicine, 1991). It is of interest that a vast majority of the Americans surveyed recently supported expanded medical research on aging. The survey was conducted for the Alliance of Aging Research by an independent public opinion research firm. Eight of ten people polled (82%) said that health care reform efforts should include an emphasis on research to cure and prevent diseases affecting older people. In addition, more than seven of ten people (76%) polled agreed that spending money on medical research now as a means of reducing future health care costs for the elderly is an important mission. Support for these views transcended political party lines (Alliance for Aging Research, 1993). PHYSICIANS FOR CLINICAL NEEDS In its 1987 document Personnel for Health Needs of the Elderly through Year 2020, the National Institute on Aging estimated the need for clinical/consultative geriatricians for the year 2000 to range between 9,000 and

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions 29,000, depending upon the mode of geriatric practice and whether the care of older people would be improved. For the year 2020, the range of estimates was between 13,000 and 42,000. More recent projections of the physician supply needed to care for older people focused initially on the target year 2000 and provided estimates under three economic scenarios (moderate growth, recessionary economy, and steady growth). All nonsurgical specialties were included in the model. The result of the study suggested that by the year 2000 the number of FTE physicians needed to provide medical care for older people will increase above the mid 1980s level by 34–51 percent. Estimates of the number of FTE positions in the primary care specialties of internal medicine and family and general practice needed in the year 2000 were far greater (146–151 percent) than the largest need projected by the NIA for that year. This analysis assumed that primary care physicians would continue to provide the bulk of this care (62–69 percent depending on the scenario). For the year 2000, the model estimated that somewhere between 3,668 and 9,705 geriatricians would be needed to provide clinical care for older people. The need for geriatrician services was based on the estimates of an expert panels' estimates of the percentage of older people who would need to see a geriatrician because of the complexity of their biopsychosocial problems or for geriatric assessment to prevent decline (Reuben et al., 1993b). The American Association for Geriatric Psychiatry (AAGP) has estimated the total supply of certified geriatric psychiatrists by the year 2010 to be 2,980 assuming that there are 676 certifiable specialists without fellowship training, that the number of individuals in graduate fellowship programs was at maximum capacity for 18 years, and that an additional 50 graduates entered into new fellowship programs for 9 years. The assumption of 676 certified geriatric psychiatrists without fellowship training may be low because this pathway is available for only 5 years. The AAGP also estimates that there will be 7,479,000 mentally ill elderly people by the year 2010, which would require a caseload of 2,500 patients per geriatric psychiatrist and only 1.0 hour per patient per year to render all diagnostic and treatment services (Small et al., 1988; Jeffrey Foster, AAGP, personal communication, 1993). The degree to which non-primary-care specialists will care for the clinical needs of older people has not been determined. Nevertheless, in these nonmedical specialties, the care of older people plays an important role. Data from the National Ambulatory Medical Care Survey (NAMCS) (Table 6) indicate the percentages of all ambulatory visits to various specialties are by people age 65 or older. Over 45 percent of visits to urologists, ophthalmologists, and cardiologists in 1991 were by people age 65 or older. In addition, more than 30 percent of the visits to general surgeons and internists were by people age 65 or older (David Woodwell, National Ambulatory Medical Care Survey, personal communication, 1993).

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions TABLE 6 Ambulatory Visits to Various Medical Specialties by People Age 65 and Older   Percentage of Total Visits in: Specialty 1978 1981 1985 1991 All specialties 16.1 18.4 20.1 23.2 General/family practice 17.1 19.3 19.6 19.9 Internal medicine 31.1 34.4 39.2 37.7 Cardiology 39.1 46.1 47.2 53.4 Opthalmology 30.0 39.3 43.8 55.0 Urology 29.9 37.6 39.6 45.8 General surgery 21.9 20.1 27.2 32.2 Neurology 13.2 17.7 21.0 19.9 Dermatology 12.2 13.4 18.3 27.9 Otolaryngology 14.1 16.9 17.0 17.7 Orthopedic surgery 10.9 13.7 13.9 17.9 Psychiatry 4.5 4.6 6.5 7.0 Obstetrics/gynecology 2.2 2.6 3.3 4.5 Other 5.0 6.0 10.2 12.2 SOURCE: National Ambulatory Medical Care Survey, National Center for Health Statistics. The preparation of trainees in non-primary-care specialties for caring for older people has been limited. In their survey of surgical residency programs, Friedman and colleagues (Trustees of Boston University, 1989) determined that only 24–31 percent of surgical residency programs (including general surgery, otolaryngology, orthopedics, urology, and obstetrics and gynecology) provided formal training on mental status assessment. Between 22 and 50 percent (the highest being orthopedics) provided formal training on functional status assessment. That study also identified factors limiting the introduction of geriatrics into residency programs. The most commonly cited factors included limited time in residency, insufficient numbers of trained faculty, insufficient funds, lack of organization of geriatrics specialists, and lack of special clinical units for geriatric patients.